Sage Integrative Health
New Patient Intake Form

Hello and thank you for your interest in our services.

The below questions are part of our intake process for booking appointments. Please fill out your answers as thoroughly as possible to help us connect you with services that will best meet your needs. This form follows HIPAA Compliance Guidelines.

If you're not comfortable filling out the online form, please give us a call and we can do the intake over the phone.
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What is your full name? *
What services are you seeking? *
What is your email address? *
What is your phone number? *
Which pronouns do you use? *
What is your date of birth? *
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What is your home address? Please include your complete address including city and zip code. *
Are you currently a resident of California? *
If applicable, what concerns are you hoping to address? *
Are you currently in any form of treatment to address these concerns? Please describe the treatment(s) you are currently engaged in.
What days/times are you available for appointments? *
Are you looking for in-person, virtual, or hybrid appointments?
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What is the best way to reach you? If by phone, what are the best times? *
How did you hear about Sage Integrative Health? (if referred by a provider, please provide their name and email address if possible) *
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